When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Compare muscle strength bilaterally.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.

Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.

Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.

Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.

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Correct Answer is B

Explanation

Choice A reason: Placing a client in restraints without having a healthcare provider's order is not a tort, but a violation of the client's rights. The nurse should obtain an order for restraints as soon as possible and follow the facility's policy and procedure.

Choice B reason: Informing a client that the medication being administered is a vitamin is a tort, specifically a fraud. The nurse is deceiving the client and violating the principle of informed consent. The nurse should explain the purpose, benefits, and risks of the medication to the client and obtain the client's consent.

Choice C reason: Enlisting security personnel to assist with restraining the client is not a tort, but a prudent action. The nurse is ensuring the safety of the client and others by seeking help from trained staff. The nurse should document the incident and the rationale for the intervention.

Choice D reason: Administering the medication to a client behind a closed curtain is not a tort, but a respectful action. The nurse is maintaining the client's privacy and dignity by providing a quiet and secluded environment. The nurse should monitor the client's response and report any adverse effects.

A. Smoking cessation. B. Regular exercise. C. Low-fat diet. D. Stress reduction.

Correct Answer is A

Explanation

Choice A reason: Smoking cessation is the most important lifestyle modification for the nurse to encourage. Smoking is a major risk factor for cardiac disease, as it increases blood pressure, heart rate, and oxygen demand, and damages the blood vessels and the heart muscle. Quitting smoking can reduce the risk of cardiac disease by 50% within one year.

Choice B reason: Regular exercise is a beneficial lifestyle modification for the nurse to encourage, but not the most important one. Exercise can improve cardiovascular fitness, lower blood pressure, and reduce body weight, but it does not eliminate the harmful effects of smoking on the heart and blood vessels.

Choice C reason: A low-fat diet is a helpful lifestyle modification for the nurse to encourage, but not the most important one. A low-fat diet can lower cholesterol levels and prevent atherosclerosis, but it does not reverse the damage caused by smoking to the heart and blood vessels.

Choice D reason: Stress reduction is a useful lifestyle modification for the nurse to encourage, but not the most important one. Stress can trigger the release of hormones that increase blood pressure, heart rate, and oxygen demand, and can also lead to unhealthy behaviors such as smoking, overeating, and alcohol abuse. However, stress reduction alone does not address the direct effects of smoking on the heart and blood vessels.

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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